Spontaneous abortion: a randomized, controlled trial comparing surgical evacuation with conservative management using misoprostol

The association between history of retained placenta and success rate of misoprostol treatment for early pregnancy failure

BACKGROUND

To date, the association between retained placenta and treatment success rate of misoprostol for early pregnancy failure has yet to be evaluated. The aim of this study was to evaluate this association and further investigated the connection between medical, clinical and sonographic parameters and treatment success.

METHODS

We conducted a retrospective cohort study of women with early pregnancy failure treated with misoprostol from 2006 to 2021. The success rate of misoprostol treatment was compared between patients with history of retained placenta including women who underwent manual lysis of the placenta following delivery or patients who were found to have retained products of conception during their post-partum period (study group) and patients without such history (controls). Demographic, clinical, and sonographic characteristics as well as treatment outcomes were compared between the groups.

RESULTS

A total of 271 women were included in the study (34 women in the study group compared to 237 women in the control group). Two-hundred and thirty-three women (86.0%) presented with missed abortion, and 38 (14.0%) with blighted ovum. Success rates of misoprostol treatment were 61.8% and 78.5% for the study and control groups, respectively (p = 0.032). Univariate analysis performed comparing successful vs. failed misoprostol treatment showed advanced age, gravidity, parity and gestational sac size (mm) on TVUS were associated with higher misoprostol treatment failure rate. Following a multivariate logistic regression model these variables did not reach statistical significance.

CONCLUSION

Women who have an event of retained placenta following childbirth appear to have decreased success rate of treatment with misoprostol for early pregnancy failure. Larger studies are needed to confirm this finding.

Reproductive outcome after early miscarriage: comparing vaginal misoprostol treatment with expectant management in a planned secondary analysis of a randomized controlled trial

OBJECTIVE

To compare the reproductive outcome after early miscarriage between women managed expectantly and those treated with vaginal misoprostol.

METHODS

This study was a planned secondary analysis of data collected prospectively in a randomized controlled trial comparing expectant management with vaginal misoprostol treatment (single dose of 800 µg) in women with early embryonic or anembryonic miscarriage and vaginal bleeding. The outcome measures were the number of women with a clinical pregnancy conceived within 14 months after complete miscarriage and the outcome of these pregnancies in terms of live birth, miscarriage, ectopic pregnancy and legal termination of pregnancy. The participants replied to a questionnaire sent by post covering their reproductive history ≤ 14 months after the index miscarriage was complete. Supplementary information and data for women who did not return their questionnaire were retrieved from medical records.

RESULTS

Of 94 women randomized to misoprostol treatment and 95 allocated to expectant management, 94 and 90 women, respectively, were included for analysis. Information on reproductive outcome was available for 89/94 (95%) and 83/90 (92%) women, respectively. Complete miscarriage without surgical evacuation was achieved within 31 days in 85% (76/89) of the women in the misoprostol group and in 65% (54/83) of those managed expectantly. The proportion of women treated with surgical evacuation was 33% (27/83) in the expectant-management group vs 12% (11/89) in the misoprostol group. At 14 months after the index miscarriage was complete, 75% (67/89) of women treated with misoprostol and 75% (62/83) of those managed expectantly had achieved at least one clinical pregnancy, while 40% (36/89) and 35% (29/83), respectively, had had at least one live birth (mean difference, 5.5% (95% CI, -9.7 to 20.3%)). When considering the outcome of all pregnancies conceived within 14 months after the index miscarriage was complete, 63% (56/89) of women in the misoprostol group and 55% (46/83) of those in the expectant-management group delivered a live baby after a pregnancy (mean difference, 7.5% (95% CI, -7.9 to 22.4%)).

CONCLUSION

Women with early miscarriage can be reassured that fertility is similar after misoprostol treatment and expectant management. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Methods for managing miscarriage: a network meta-analysis

BACKGROUND

Miscarriage, defined as the spontaneous loss of a pregnancy before 24 weeks' gestation, is common with approximately 25% of women experiencing a miscarriage in their lifetime. An estimated 15% of pregnancies end in miscarriage. Miscarriage can lead to serious morbidity, including haemorrhage, infection, and even death, particularly in settings without adequate healthcare provision. Early miscarriages occur during the first 14 weeks of pregnancy, and can be managed expectantly, medically or surgically. However, there is uncertainty about the relative effectiveness and risks of each option.

OBJECTIVES

To estimate the relative effectiveness and safety profiles for the different management methods for early miscarriage, and to provide rankings of the available methods according to their effectiveness, safety, and side-effect profile using a network meta-analysis.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth's Trials Register (9 February 2021), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (12 February 2021), and reference lists of retrieved studies.

SELECTION CRITERIA

We included all randomised controlled trials assessing the effectiveness or safety of methods for miscarriage management. Early miscarriage was defined as less than or equal to 14 weeks of gestation, and included missed and incomplete miscarriage. Management of late miscarriages after 14 weeks of gestation (often referred to as intrauterine fetal deaths) was not eligible for inclusion in the review. Cluster- and quasi-randomised trials were eligible for inclusion. Randomised trials published only as abstracts were eligible if sufficient information could be retrieved. We excluded non-randomised trials.

DATA COLLECTION AND ANALYSIS

At least three review authors independently assessed the trials for inclusion and risk of bias, extracted data and checked them for accuracy. We estimated the relative effects and rankings for the primary outcomes of complete miscarriage and composite outcome of death or serious complications. The certainty of evidence was assessed using GRADE. Relative effects for the primary outcomes are reported subgrouped by the type of miscarriage (incomplete and missed miscarriage). We also performed pairwise meta-analyses and network meta-analysis to determine the relative effects and rankings of all available methods.

MAIN RESULTS

Our network meta-analysis included 78 randomised trials involving 17,795 women from 37 countries. Most trials (71/78) were conducted in hospital settings and included women with missed or incomplete miscarriage. Across 158 trial arms, the following methods were used: 51 trial arms (33%) used misoprostol; 50 (32%) used suction aspiration; 26 (16%) used expectant management or placebo; 17 (11%) used dilatation and curettage; 11 (6%) used mifepristone plus misoprostol; and three (2%) used suction aspiration plus cervical preparation. Of these 78 studies, 71 (90%) contributed data in a usable form for meta-analysis. Complete miscarriage Based on the relative effects from the network meta-analysis of 59 trials (12,591 women), we found that five methods may be more effective than expectant management or placebo for achieving a complete miscarriage: · suction aspiration after cervical preparation (risk ratio (RR) 2.12, 95% confidence interval (CI) 1.41 to 3.20, low-certainty evidence), · dilatation and curettage (RR 1.49, 95% CI 1.26 to 1.75, low-certainty evidence), · suction aspiration (RR 1.44, 95% CI 1.29 to 1.62, low-certainty evidence), · mifepristone plus misoprostol (RR 1.42, 95% CI 1.22 to 1.66, moderate-certainty evidence), · misoprostol (RR 1.30, 95% CI 1.16 to 1.46, low-certainty evidence). The highest ranked surgical method was suction aspiration after cervical preparation. The highest ranked non-surgical treatment was mifepristone plus misoprostol. All surgical methods were ranked higher than medical methods, which in turn ranked above expectant management or placebo. Composite outcome of death and serious complications Based on the relative effects from the network meta-analysis of 35 trials (8161 women), we found that four methods with available data were compatible with a wide range of treatment effects compared with expectant management or placebo: · dilatation and curettage (RR 0.43, 95% CI 0.17 to 1.06, low-certainty evidence), · suction aspiration (RR 0.55, 95% CI 0.23 to 1.32, low-certainty evidence), · misoprostol (RR 0.50, 95% CI 0.22 to 1.15, low-certainty evidence), · mifepristone plus misoprostol (RR 0.76, 95% CI 0.31 to 1.84, low-certainty evidence). Importantly, no deaths were reported in these studies, thus this composite outcome was entirely composed of serious complications, including blood transfusions, uterine perforations, hysterectomies, and intensive care unit admissions. Expectant management and placebo ranked the lowest when compared with alternative treatment interventions. Subgroup analyses by type of miscarriage (missed or incomplete) agreed with the overall analysis in that surgical methods were the most effective treatment, followed by medical methods and then expectant management or placebo, but there are possible subgroup differences in the effectiveness of the available methods.  AUTHORS' CONCLUSIONS: Based on relative effects from the network meta-analysis, all surgical and medical methods for managing a miscarriage may be more effective than expectant management or placebo. Surgical methods were ranked highest for managing a miscarriage, followed by medical methods, which in turn ranked above expectant management or placebo. Expectant management or placebo had the highest chance of serious complications, including the need for unplanned or emergency surgery. A subgroup analysis showed that surgical and medical methods may be more beneficial in women with missed miscarriage compared to women with incomplete miscarriage. Since type of miscarriage (missed and incomplete) appears to be a source of inconsistency and heterogeneity within these data, we acknowledge that the main network meta-analysis may be unreliable. However, we plan to explore this further in future updates and consider the primary analysis as separate networks for missed and incomplete miscarriage.

Conception rates after medical versus surgical evacuation of early miscarriage

OBJECTIVE

To compare short-term fertility rates after medical and surgical management of early miscarriage.

DESIGN

Observational cohort study.

SETTING

Academic tertiary-care medical center.

PATIENT(S)

A total of 203 patients were enrolled between June 2017 and May 2018, comprising 106 surgical evacuations and 97 medical evacuations.

INTERVENTION(S)

Either surgical or medical evacuation of the uterine cavity.

MAIN OUTCOME MEASURE(S)

Conception rates 6 months after miscarriage.

RESULT(S)

Conception rates 6 months after miscarriage among women who had attempted to become pregnant were similar between the medically and surgically evacuated groups (68.0% vs. 65.1%). There were no significant differences in background characteristics between the groups, apart from younger age and earlier gestational age among the medically treated group. There was no difference in the proportion of women using assisted reproductive technologies between the medically and surgically managed groups (15.5% vs. 12.6%, respectively). The median time-to-conception was 4 ± 2 months in both groups. Cumulative pregnancy rate 12 months after pregnancy loss, live birth rate, and repeat miscarriage rate also were similar between groups.

CONCLUSION(S)

Modality of uterine evacuation after early miscarriage does not affect short-term fertility outcomes.

Outcomes in prevention and management of miscarriage trials: a systematic review

BACKGROUND

There is a substantial body of research evaluating ways to prevent and manage miscarriage, but all studies do not report on the same outcomes.

OBJECTIVE

To review systematically, outcomes reported in existing miscarriage trials.

SEARCH STRATEGY

MEDLINE, Embase, CINAHL, and Cochrane were searched from inception until January 2017.

SELECTION CRITERIA

Randomised controlled trials (RCTs) reporting prevention or management of miscarriage. Miscarriage was defined as a pregnancy loss in the first trimester.

DATA COLLECTION AND ANALYSIS

Data about the study characteristics, primary, and secondary outcomes were extracted.

MAIN RESULTS

We retrieved 1553 titles and abstracts, from which 208 RCTs were included. For prevention of miscarriage, the most commonly reported primary outcome was live birth and the top four reported outcomes were pregnancy loss/stillbirth (n = 112), gestation of birth (n = 68), birth dimensions (n = 65), and live birth (n = 49). For these four outcomes, 58 specific measures were used for evaluation. For management of miscarriage, the most commonly reported primary outcome was efficacy of treatment. The top four reported outcomes were bleeding (n = 186), efficacy of miscarriage treatment (n = 105), infection (n = 97), and quality of life (n = 90). For these outcomes, 130 specific measures were used for evaluation.

CONCLUSIONS

Our review found considerable variation in the reporting of primary and secondary outcomes along with the measures used to assess them. There is a need for standardised patient-centred clinical outcomes through the development of a core outcome set; the work from this systematic review will form the foundation of the core outcome set for miscarriage.

TWEETABLE ABSTRACT

There is disparity in the reporting of outcomes and the measures used to assess them in miscarriage trials.

Association between uterine position and transvaginal misoprostol treatment for early pregnancy failure

AIM

We aimed to determine the importance of uterine position as a predicting factor of success rate in medically treated early pregnancy failure (EPF).

METHODS

We carried out a retrospective cohort study at the Obstetrics and Gynecology Department of a tertiary medical center between January 2011 and June 2012. We included women diagnosed with EPF, which we defined as women diagnosed with missed abortion up to 13 gestational weeks. Patients were treated with one or two doses of 800 μg of misoprostol vaginally in accordance with the department's protocol. Demographic, clinical, and treatment success data were collected from patient electronic records.

RESULTS

A total of 255 women were included in our study. The success rate after treatment with misoprostol for the anterior uterine group was 78.7% as compared to the non-anterior uterine group, which achieved a success rate of 88.1%. This difference was not statistically significant (P = 0.180). In a multivariate analysis comparing patients for whom treatment with misoprostol was successful as opposed to patients for whom treatment failed, only embryonic sac size showed a statistically significant difference, measuring shorter in the success group.

CONCLUSION

Uterine position has no effect on success rate of misoprostol treatment for EPF.

[Expectant therapy versus curettage for retained products of conception after second trimester termination of pregnancy: analysis of outcomes and complications]

OBJECTIVE

To evaluate the prognosis and complications of expectant therapy and curettage for retained product of conception (RPOC) after second trimester termination of pregnancy (TOP).

METHODS

A total of 270 patients with RPOC following second trimester TOP in Nanfang Hospital between January, 2014 and December, 2015 were included in this study. The duration of vaginal bleeding time and menstruation recovery interval were compared between patients receiving expectant therapy and curettage for RPOC, and binary logistic regression was used to assess the risk factors for complications in bivariate and multivariate analyses.

RESULTS

The duration of vaginal bleeding time was significantly longer in expectant therapy group than in curettage group (P=0.005), while the menstruation recovery interval did not differ significantly between the two groups. The incidence of vaginal bleeding time for over 42 days was significantly higher in curettage group than in expectant therapy group (P=0.040), and the incidence of a menstruation recovery interval beyond 60 days was comparable between them. The incidence of complications was significantly higher in curettage group than in expectant therapy group either with adjustment of age, gravidity, parity, history of uterine surgery status, gestational age, type of indications, regimens for TOP and induction-abortion interval (OR=18.26[95% CI: 3.57-93.42], P < 0.001) or without adjustment (OR=10.60, [95% CI: 2.36-47.66], P=0.002).

CONCLUSION

Expectant therapy and curettage for RPOC after second trimester TOP have comparable prognosis, but curettage is associated with a significantly higher rate of complications.

Medical treatments for incomplete miscarriage

BACKGROUND

Miscarriage occurs in 10% to 15% of pregnancies. The traditional treatment, after miscarriage, has been to perform surgery to remove any remaining placental tissues in the uterus ('evacuation of uterus'). However, medical treatments, or expectant care (no treatment), may also be effective, safe, and acceptable.

OBJECTIVES

To assess the effectiveness, safety, and acceptability of any medical treatment for incomplete miscarriage (before 24 weeks).

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (13 May 2016) and reference lists of retrieved papers.

SELECTION CRITERIA

We included randomised controlled trials comparing medical treatment with expectant care or surgery, or alternative methods of medical treatment. We excluded quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies for inclusion, assessed risk of bias, and carried out data extraction. Data entry was checked. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included 24 studies (5577 women). There were no trials specifically of miscarriage treatment after 13 weeks' gestation.Three trials involving 335 women compared misoprostol treatment (all vaginally administered) with expectant care. There was no difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; 2 studies, 150 women, random-effects; very low-quality evidence), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; 2 studies, 308 women, random-effects; low-quality evidence). There were few data on 'deaths or serious complications'. For unplanned surgical intervention, we did not identify any difference between misoprostol and expectant care (average RR 0.62, 95% CI 0.17 to 2.26; 2 studies, 308 women, random-effects; low-quality evidence).Sixteen trials involving 4044 women addressed the comparison of misoprostol (7 studies used oral administration, 6 studies used vaginal, 2 studies sublingual, 1 study combined vaginal + oral) with surgical evacuation. There was a slightly lower incidence of complete miscarriage with misoprostol (average RR 0.96, 95% CI 0.94 to 0.98; 15 studies, 3862 women, random-effects; very low-quality evidence) but with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.05, 95% CI 0.02 to 0.11; 13 studies, 3070 women, random-effects; very low-quality evidence) but more unplanned procedures (average RR 5.03, 95% CI 2.71 to 9.35; 11 studies, 2690 women, random-effects; low-quality evidence). There were few data on 'deaths or serious complications'. Nausea was more common with misoprostol (average RR 2.50, 95% CI 1.53 to 4.09; 11 studies, 3015 women, random-effects; low-quality evidence). We did not identify any difference in women's satisfaction between misoprostol and surgery (average RR 1.00, 95% CI 0.99 to 1.00; 9 studies, 3349 women, random-effects; moderate-quality evidence). More women had vomiting and diarrhoea with misoprostol compared with surgery (vomiting: average RR 1.97, 95% CI 1.36 to 2.85; 10 studies, 2977 women, random-effects; moderate-quality evidence; diarrhoea: average RR 4.82, 95% CI 1.09 to 21.32; 4 studies, 757 women, random-effects; moderate-quality evidence).Five trials compared different routes of administration, or doses, or both, of misoprostol. There was no clear evidence of one regimen being superior to another. Limited evidence suggests that women generally seem satisfied with their care. Long-term follow-up from one included study identified no difference in subsequent fertility between the three approaches.

AUTHORS' CONCLUSIONS

The available evidence suggests that medical treatment, with misoprostol, and expectant care are both acceptable alternatives to routine surgical evacuation given the availability of health service resources to support all three approaches. Further studies, including long-term follow-up, are clearly needed to confirm these findings. There is an urgent need for studies on women who miscarry at more than 13 weeks' gestation.

Effect of Uterine Cavity Sonographic Measurements on Medical Management Failure in Women With Early Pregnancy Loss

OBJECTIVES

Medical management is commonly used among women with early pregnancy failure. The purpose of our study was to evaluate uterine content sonographic measurements for predicting medical management failure in early pregnancy loss.

METHODS

We conducted a retrospective cohort study in a university-affiliated hospital center including all women discharged from the emergency department (ED) with a diagnosis of early pregnancy failure who had medical management with misoprostol between 2011 and 2013. Only women with sonograms available for review were included in our study. All images were reviewed and the following cavity measurements, excluding the endometrial lining, were measured: cavity anteroposterior distance, cavity longitudinal distance, cavity transverse distance, and cavity volume. Logistic regression analysis was used to identify measurements that were independently associated with a subsequent need for dilation and curettage (D&C) and an unplanned return to the ED.

RESULTS

Among 823 women presenting to the ED with first-trimester bleeding, 227 met inclusion criteria. Of all measurements evaluated, the cavity anteroposterior distance was found to be independently associated with D&C and an unplanned return to the ED. When a cavity anteroposterior distance cutoff of 15 mm was used, women were more likely to require D&C (adjusted odds ratio, 2.65; 95% confidence interval, 1.31-5.36; P< .01) and to have an unplanned return to the ED (adjusted odds ratio, 2.59; 95% confidence interval, 1.41-4.79; P < .01). In women with a cavity anteroposterior distance of less than 15 mm, 87.1% had successful medical management of early pregnancy loss, and 80.0% did not require an unplanned return to the ED.

CONCLUSIONS

Although there is a need for further validation, patients identified as having a cavity anteroposterior distance of less than 15 mm should be considered good candidates for successful medical management.

Expectant Versus Surgical Management of Early Pregnancy Miscarriages- A Prospective Study

BACKGROUND

Surgical, medical and expectant management are the various options available to manage early pregnancy miscarriages; each with its own merits and demerits. In the last two decades, the efficacy and safety of expectant management which allows for the spontaneous passage of retained products of conception has been studied and confirmed.

AIM

To compare the safety and efficacy of expectant management of early pregnancy miscarriages with surgical uterine evacuation.

MATERIALS AND METHODS

The prospective study conducted in tertiary care centre for 5 years, included 212 patients with USG confirmed pregnancy miscarriages of less than 13 weeks, who were allocated to expectant management (Cases, n=112) and surgical evacuation (Control, n=100). Patients were allocated for expectant management as outpatients for 2 weeks, without any intervention till they had spontaneous complete miscarriage which was confirmed by sonography. Those who failed to do so, underwent a planned surgical uterine evacuation. Emergency admission and evacuation was done, if the patients became symptomatic in the waiting period. Patients allocated to surgical group underwent planned surgical evacuation once diagnosed. Success rate and complications like emergency evacuation, vaginal bleeding, abdominal pain, limitation of physical activity and patient satisfaction were assessed. Both groups were followed up for 6 more weeks. Statistical analysis was done with Z-test.

RESULTS

Success rate of the expectant management was 71% as against 97% in surgical group. Severe vaginal bleeding was comparable (5% in both groups), 8% of expectant had severe abdominal pain versus 4% in surgical group. Unplanned admissions and emergency evacuation rate was high in expectant 9% against 1% in surgical group. Twenty one percent patients in expectant and 17% patients in surgical group experienced limitation of physical activity. Overall patient satisfaction rate was comparable (74% in expectant 80% in surgical group).

CONCLUSION

Expectant management of miscarriages has a success rate of 71%. Compared to surgical management, abdominal pain, unplanned admissions, emergency evacuation and limitation of physical activity were more in expectant group. Success rate can be improved and complications can be minimised with proper patient selection and counseling.

Uterine artery Doppler in the management of early pregnancy loss: a prospective, longitudinal study

Background

The pharmacological management of early pregnancy loss reduced substantially the need for dilation and curettage. However, prognostic markers of successful outcome were not established. Thus the major purpose of this study was to determine the sensitivity and specificity of the uterine artery pulsatility (PI) and resistance (RI) indices to detect early pregnancy loss patients requiring dilation and curettage after unsuccessful management.

Methods

A cohort prospective observational study was undertaken to include women with early pregnancy loss, ≤ 12 weeks of gestation, managed with mifepristone (200 mg) and misoprostol (1600 μg) followed by PI and RI evaluation of both uterine arteries 2 weeks after. At this time, in 173/315 patients, incomplete miscarriage was diagnosed. Among them, 32 underwent uterine dilatation and curettage at 8 weeks of follow-up.

Results

The cut-off points for the uterine artery PI and RI, leading to the maximum values of sensitivity (69.5%, CI_95%: 61.5%-76.5% and 75.0%, CI_95%: 57.9%-86.8%, respectively) and specificity (75.0%, CI_95%: 57.9%-86.8% and 65.6%, CI_95%: 48.3%-79.6%, respectively), for the discrimination between the women who needed curettage from those who resolved spontaneously were 2.8 and 1, respectively.

Conclusions

The potential usefulness of uterine artery Doppler evaluation to predict the need for uterine curettage in patients submitted to medical treatment for early pregnancy loss was demonstrated.

Outpatient versus inpatient intravaginal misoprostol for the treatment of first trimester incomplete miscarriage: a randomised controlled trial

BACKGROUND

Study objective To assess the efficacy of outpatient misoprostol administration versus inpatient misoprostol administration for the treatment of first trimester incomplete miscarriage.

MATERIALS AND METHODS

A prospective randomised controlled trial was conducted at a tertiary hospital from May 2012 to April 2013. A total of 154 patients with first trimester incomplete miscarriage were randomised to receive misoprostol either as outpatient or inpatient. Intra-vaginal misoprostol 800 mcg was administered eight hourly to a maximum of three doses. Complete evacuation is achieved when the cervical os was closed on vaginal examination or ultrasound showed no more retained products of conception evidenced by endometrial thickness of less than 15 mm. Treatment failure was defined as failure in achieving complete evacuation on day seven hence surgical evacuation is offered.

RESULTS

Outpatient administration of misoprostol was as effective as inpatient treatment with success rate of 89.2 and 85.7 % (p = 0.520). The side effects were not significantly different between the two groups. Side effects that occurred were minor and only required symptomatic treatment. Duration of bleeding was 6.0 days in both groups (p = 0.317). Mean reduction in haemoglobin was lesser in the outpatient group (0.4 g/dl) as compared to in the inpatient group (0.6 g/dl) which was statistically significant (p = 0.048).

CONCLUSION

Medical evacuation using intra-vaginal misoprostol 800 mcg eight hourly for a maximum of three doses in an outpatient setting is as effective as in inpatient setting with tolerable side effects.

A randomised controlled trial of expectant management versus surgical evacuation of early pregnancy loss

OBJECTIVE

To show whether a clinically significant difference in success rates exists between expectant and surgical management of early pregnancy loss.

STUDY DESIGN

Randomised controlled trial comparing expectant versus surgical management of early pregnancy loss over a 1-year period from 1st January to 31st December 2009 at Sultanah Aminah Hospital, Johor Bahru. Pregnant women with missed or incomplete miscarriages at gestations up to 14 weeks were recruited in this study. The success rate in the surgical group was measured as curettage performed without any complications during or after the procedure, while the success rate in the expectant group was defined as complete spontaneous expulsion of products of conception within 6 weeks without any complication.

RESULTS

A total of 360 women were recruited and randomised to expectant or surgical management, with 180 women in each group. There was no statistically significant difference in the success rate between the groups and between the different types of miscarriage. With expectant management, 131 (74%) patients had a complete spontaneous expulsion of products of conception, of whom 106 (83%) women miscarried within 7 days. However, the rates of unplanned admissions (18.1%) and unplanned surgical evacuations (17.5%) in the expectant group were significantly higher than the rates (7.4% and 8% respectively) in the surgical group. The complications in both groups were similar.

Expectant versus surgical management of first-trimester miscarriage: a randomised controlled study

INTRODUCTION

The aim of this study is to compare the efficacy and safety of expectant management with surgical management of first-trimester miscarriage.

METHODS

This randomised prospective study was conducted in the Gynaecology Department at University of Saarland Hospital, Germany between February 2011 and April 2012. A total of 234 women were recruited following diagnosis of the first-trimester incomplete or missed miscarriage and randomised into two groups: 109 women were randomised to expectant management (group I), and 125 women to surgical management (groupII). All women were examined clinically and sonographically during the follow-up appointments at weekly intervals for up to 4 weeks as appropriate. The outcome measures were: efficacy, short-term complications and duration of vaginal bleeding and pain.

RESULTS

Of 234 eligible women, 17 were lost to follow-up, and the remaining 217 women were analysed. The baseline characteristics were similar in both groups. The total success rate at 4 weeks was lower for expectant than for surgical management (81.4 vs 95.7 %; P = 0.0029). The type of miscarriage was a significant factor affecting the success rate. For missed miscarriage, the success rates for expectant versus surgical management were 75 and 93.8 %, respectively. For women with incomplete miscarriage, the rates were 90.5 and 98 %. No differences were found in the number of emergency curettages between the two study groups. The duration of bleeding was significantly more in the expectant than the surgical management (mean 11 vs 7 days; P < 0.0001). The duration of pain was also more in the expectant than the surgical group (mean 8.1 vs 5.5 days; P < 0.0001). The total complication rates were similar in both groups (expectant 5.9 % vs surgical group 6.1 %; P = 0.2479). However, the pelvic infection was significantly lower in the expectant than the surgical group (1.9 vs 3.5 %, respectively; P = 0.0146).

CONCLUSION

Expectant management of clinically stable women with first-trimester miscarriage is safe and effective and avoids the need for surgery and the subsequent risk of anaesthesia in about 81.4 % of cases, and has lower pelvic infection rate than surgical curettage. However, surgical management is more successful, and with a shorter duration of bleeding and pain. Therefore, the patient's preference should be considered in the counselling process.

Systematic review and meta-analysis of intrauterine adhesions after miscarriage: prevalence, risk factors and long-term reproductive outcome

BACKGROUND

Approximately 15-20% of all clinically confirmed pregnancies end in a miscarriage. Intrauterine adhesions (IUAs) are a possible complication after miscarriage, but their prevalence and the contribution of possible risk factors have not been elucidated yet. In addition, the long-term reproductive outcome in relation to IUAs has to be elucidated.

METHODS

We systematically searched the literature for studies that prospectively assessed the prevalence and extent of IUAs in women who suffered a miscarriage. To be included, women diagnosed with a current miscarriage had to be systematically evaluated within 12 months by hysteroscopy after either spontaneous expulsion or medical or surgical treatment. Studies that included women with a history of recurrent miscarriage only or that evaluated the IUAs after elective abortion or beyond 12 months after the last miscarriage were not included. Subsequently, long-term reproductive outcomes after expectant (conservative), medical or surgical management were assessed in women with and without post-miscarriage IUAs.

RESULTS

We included 10 prospective studies reporting on 912 women with hysteroscopic evaluation within 12 months of miscarriage and 8 prospective studies, including 1770 women, reporting long-term reproductive outcome. IUAs were detected in 183 women, resulting in a pooled prevalence of 19.1% [95% confidence interval (CI): 12.8-27.5%]. The extent of IUAs was reported in 124 women (67.8%) and was mild, moderate and severe respectively in 58.1, 28.2 and 13.7% of cases. Relative to women with one miscarriage, women with two or three or more miscarriages showed an increased risk of IUAs by a pooled OR of 1.41 and 2.1, respectively. The number of dilatation and curettage (D&C) procedures seemed to be the main driver behind these associations. A total of 150 congenital and acquired intrauterine abnormalities were encountered in 675 women, resulting in a pooled prevalence of 22.4% (95% CI: 16.3-29.9%). Similar reproductive outcomes were reported subsequent to conservative, medical or surgical management for miscarriage, although the numbers of studies and of included women were limited. No studies reported long-term reproductive outcomes following post-miscarriage IUAs.

CONCLUSIONS

IUAs are frequently encountered, in one in five women after miscarriage. In more than half of these, the severity and extent of the adhesions was mild, with unknown clinical relevance. Recurrent miscarriages and D&C procedures were identified as risk factors for adhesion formation. Congenital and acquired intrauterine abnormalities such as polyps or fibroids were frequently identified. There were no studies reporting on the link between IUAs and long-term reproductive outcome after miscarriage, while similar pregnancy outcomes were reported subsequent to conservative, medical or surgical management. Although this review does not allow strong clinical conclusions on treatment management, it signals an important clinical problem. Treatment strategies are proposed to minimize the number of D&C in an attempt to reduce IUAs.

Prediction of successful expectant management of first trimester miscarriage: development and validation of a new mathematical model

OBJECTIVE

To generate and evaluate a new logistic regression model for the prediction of successful expectant management of first trimester miscarriage.

METHODS

Data were collected prospectively from women diagnosed with 1st trimester miscarriage. Clinical and ultrasonographic variables were recorded for multivariate analysis. Clinically stable women who were managed expectantly were followed up for two weeks until the outcome was established: success or failure. A multinomial logistic regression (MLR) model was developed on 186 training cases for the prediction of successful expectant management and tested prospectively on a further 126 cases. The performance of the model was evaluated using receiver operating characteristic (ROC) curve as well as in terms of sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).

RESULTS

Two thousand and forty eight consecutive first trimester women underwent TVS. Complete data from 312 (15.2%) women with miscarriage managed expectantly were included in the final analysis. The most important independent prognostic variables for the MLR model were as follows: type of miscarriage at primary scan, vaginal bleeding and maternal age. When developed retrospectively on a training data set, MLR model gave an area under the ROC curve (AUC) of 0.796. Prospective validation of MLR model on a new test data set resulted in an AUC of 0.803.

CONCLUSION

We have developed and validated a new mathematical model to predict successful management of first trimester miscarriage.

Medical treatments for incomplete miscarriage

BACKGROUND

Miscarriage occurs in 10% to 15% of pregnancies. The traditional treatment, after miscarriage, has been to perform surgery to remove any remaining placental tissues in the uterus ('evacuation of uterus'). However, medical treatments, or expectant care (no treatment), may also be effective, safe and acceptable.

OBJECTIVES

To assess the effectiveness, safety and acceptability of any medical treatment for incomplete miscarriage (before 24 weeks).

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2012) and reference lists of retrieved papers.

SELECTION CRITERIA

Randomised controlled trials comparing medical treatment with expectant care or surgery or alternative methods of medical treatment. Quasi-randomised trials were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked.

MAIN RESULTS

Twenty studies (4208 women) were included. There were no trials specifically of miscarriage treatment after 13 weeks' gestation.Three trials involving 335 women compared misoprostol treatment (all vaginally administered) with expectant care. There was no statistically significant difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; two studies, 150 women, random-effects), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; two studies, 308 women, random-effects). There were few data on 'deaths or serious complications'.Twelve studies involving 2894 women addressed the comparison of misoprostol (six studies used oral administration, four studies used vaginal, one study sub-lingual, one study combined vaginal + oral) with surgical evacuation. There was a slightly lower incidence of complete miscarriage with misoprostol (average RR 0.97, 95% CI 0.95 to 0.99, 11 studies, 2493 women, random-effects) but with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.06, 95% CI 0.02 to 0.13; 11 studies, 2654 women, random-effects) but more unplanned procedures (average RR 5.82, 95% CI 2.93 to 11.56; nine studies, 2274 women, random-effects). There were few data on 'deaths or serious complications'. Nausea was more common with misoprostol (average RR 2.41, 95% CI 1.44 to 4.03; nine studies, 2179 women, random-effects).Five trials compared different routes of administration and/or doses of misoprostol. There was no clear evidence of one regimen being superior to another. Limited evidence suggests that women generally seem satisfied with their care. Long-term follow-up from one included study identified no difference in subsequent fertility between the three approaches.

AUTHORS' CONCLUSIONS

The available evidence suggests that medical treatment, with misoprostol, and expectant care are both acceptable alternatives to routine surgical evacuation given the availability of health service resources to support all three approaches. Women experiencing miscarriage at less than 13 weeks should be offered an informed choice. Future studies should include long-term follow-up.

Can we use a lower intravaginal dose of misoprostol in the medical management of miscarriage? A randomised controlled study

BACKGROUND

The optimal dose of misoprostol to be used in the medical management of miscarriage before 13 weeks has not been resolved.

AIM

To evaluate the effectiveness and side effect profile of two different dosages of misoprostol.

METHODS

A randomised controlled, equivalence study comparing 400 vs 800 μg misoprostol per vaginum (PV) on an outpatient basis. The allocated dose was repeated the next day if clinically the products of conception had not been passed. Complete miscarriage was evaluated using two methods: ultrasound criteria on Day 7 and the need for surgical management (clinical criteria). Equivalence was demonstrated if the 95% confidence interval [CI] of the observed risk difference between the two doses for complete miscarriage lay between -15.0 and 15.0%. Differences in side effects and patient satisfaction were evaluated using patient-completed questionnaires.

RESULTS

One hundred and fifty-eight women were allocated to receive 400 μg and 152 women to 800 μg misoprostol for the management of missed (91.3%) or incomplete (8.7%) miscarriage. The rate of induced complete miscarriage was equivalent using both ultrasound criteria (observed risk difference (ORD) -4.6%, 95% CI -12.8 to 3.7%; P = 0.313) and clinical criteria (ORD -5.6%, 95% CI -14.8 to 3.6%; P = 0.273). Following the 400 μg dose, the reported rate of fever/rigors was lower (ORD -15.6%, 95% CI -28.1 to -3.0%; P = 0.015), and more women reported their decision to undergo medical management as a good decision (ORD 15.2%, 95% CI 2.8 to 27.7%; P = 0.018).

CONCLUSION

Four hundred-microgram misoprostol PV can be recommended for the medical management of miscarriage on an outpatient basis.

Oral misoprostol as an alternative to surgical management for incomplete abortion in Ghana

OBJECTIVE

To investigate whether 600-μg oral misoprostol is an effective alternative to manual vacuum aspiration (MVA) for the treatment of incomplete abortion.

METHODS

From June 16, 2004, to July 20, 2005, 230 women of reproductive age presenting with incomplete abortion were randomized in an open-label trial to either 600-μg oral misoprostol or MVA for the treatment of incomplete abortion.

RESULTS

Regardless of the assigned method, more than 98% of participants experienced complete uterine evacuation following initial treatment. Efficacy, acceptability, and satisfaction ratings were similar and high for both methods.

CONCLUSION

600-μg oral misoprostol is a safe, effective, and acceptable alternative to MVA for the treatment of incomplete abortion.

Expectant management of spontaneous first-trimester miscarriage: prospective validation of the '2-week rule'

OBJECTIVES

To assess uptake and success of expectant management of first-trimester miscarriage for a finite 14-day period, in order to evaluate our '2-week rule' of management.

METHODS

This was a prospective observational study evaluating our proposed 2-week rule of expectant management, which is based on the finding that women managed expectantly are most likely to miscarry in the first 14 days and that to wait longer than 2 weeks without intervention does not confer a greater chance of successful resolution. Eligible women diagnosed with first-trimester miscarriage were offered a choice of expectant management or surgical evacuation under general anesthesia. Inclusion criteria for expectant management were: diagnosis of incomplete miscarriage (heterogeneous tissue, with or without a gestational sac, seen on ultrasound in the uterine cavity and distorting the endometrial midline echo), missed miscarriage (crown-rump length (CRL) >or= 6 mm with absent fetal heart activity) or empty sac (anembryonic pregnancy) based on transvaginal ultrasonography. Women with complete miscarriage, missed miscarriage at the nuchal translucency scan, molar pregnancy or miscarriage >or= 3 weeks in duration (missed miscarriage in which the CRL was >or= 3 weeks smaller than the gestational age based on last menstrual period), or with signs of infection or hemodynamic instability were excluded. Expectant management consisted of weekly ultrasonography for 2 weeks. If after 2 weeks resolution was not complete, surgery was advised.

RESULTS

1062 consecutive pregnant women underwent transvaginal ultrasound examination. Of these, 38.6% (410/1062) were diagnosed with miscarriage, of whom 241 (59%) were symptomatic at the time of presentation and 282 were eligible for the study. These were offered expectant management and 80% (227/282) took up this option. 11% (24/227) were lost to follow-up; therefore, complete data were available on 203 women. Overall spontaneous resolution of miscarriage at 2 weeks was observed in 61% (124/203) of women. Rates of spontaneous resolution at 2 weeks according to the type of miscarriage were 71% for incomplete miscarriage, 53% for empty sac and 35% for missed miscarriage. The incidence of unplanned emergency dilatation and curettage due to gynecological infection or hemorrhage was 2.5% (5/203).

CONCLUSIONS

Expectant management based on the 2-week rule is a viable and safe option for women with first-trimester miscarriage. Women with an incomplete miscarriage are apparently the most suitable for expectant management.

Medical treatments for incomplete miscarriage (less than 24 weeks)

BACKGROUND

Miscarriage occurs in 10% to 15% of pregnancies. The traditional treatment, after miscarriage, has been to perform surgery to remove any remaining pregnancy tissues in the uterus. However, it has been suggested that drug-based medical treatments, or expectant care (no treatment), may also be effective, safe and acceptable.

OBJECTIVES

To assess the effectiveness, safety and acceptability of any medical treatment for early incomplete miscarriage (before 24 weeks).

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2009).

SELECTION CRITERIA

Randomised controlled trials comparing medical treatment with expectant care or surgery. Quasi-randomised trials were excluded.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked.

MAIN RESULTS

Fifteen studies (2750 women) were included, there were no studies on women over 13 weeks' gestation. Studies addressed a number of comparisons and data are therefore limited.Three trials compared misoprostol treatment (all vaginally administered) with expectant care. There was no significant difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; two studies, 150 women), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; two studies, 308 women). There were few data on 'deaths or serious complications'.Nine studies involving 1766 women addressed the comparison of misoprostol (four oral, four vaginal, one vaginal + oral) with surgical evacuation. There was no statistically significant difference in complete miscarriage (average RR 0.96, 95% CI 0.92 to 1.00, eight studies, 1377 women) with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.07, 95% CI 0.03 to 0.18; eight studies, 1538 women) but more unplanned procedures (average RR 6.32, 95% CI 2.90 to 13.77; six studies, 1158 women). There were few data on 'deaths or serious complications'. Limited evidence suggests that women generally seem satisfied with their care. Long-term follow up from one included study identified no difference in subsequent fertility between the three approaches.

AUTHORS' CONCLUSIONS

The available evidence suggests that medical treatment, with misoprostol, and expectant care are both acceptable alternatives to routine surgical evacuation given the availability of health service resources to support all three approaches. Women experiencing miscarriage at less than 13 weeks should be offered an informed choice.

Incidence of pregnancy after expectant, medical, or surgical management of spontaneous first trimester miscarriage: long term follow-up of miscarriage treatment (MIST) randomised controlled trial

OBJECTIVES

To compare fertility rates after the three methods of managing early miscarriage in women recruited to the MIST (miscarriage treatment) randomised controlled trial.

SETTING

Early pregnancy clinics of acute hospitals in the south west region of England.

PARTICIPANTS

1199 women who had had an early miscarriage (<13 weeks) confirmed by scan.

INTERVENTION

Expectant, medical, or surgical management.

MAIN OUTCOME MEASURES

Self reported pregnancy rates and live birth rates.

RESULTS

Of 1199 women recruited to the trial, 1128 consented to follow-up. Of these, 762 women replied giving pregnancy details (68% response rate). Respondents were representative of the trial participants. The live birth rate five years after the index miscarriage was similar in the three management groups: 177/224 (79%, 95% confidence interval 73% to 84%) in the expectant management group, 181/230 (79%, 73% to 84%) in the medical group, and 192/235 (82%, 76% to 86%) in the surgical group. There was also no significant difference according to previous birth history. Older women and those with previous miscarriages were significantly less likely to subsequently give birth.

CONCLUSION

Method of miscarriage management does not affect subsequent pregnancy rates with around four in five women giving birth within five years of the index miscarriage. Women can be reassured that long term fertility concerns need not affect their choice of miscarriage management.

TRIAL REGISTRATION

National Research Register N0467011677/N0467073587.

Medical management of first trimester miscarriage (blighted ovum and missed abortion): is it effective?

This prospective study of 104 women investigated the dose-related efficacy of mifepristone combined with oral misoprostol in the management of first trimester miscarriage (missed abortion and blighted ovum). Forty-four women (group A) received 600 mg of oral mifepristone and 60 women (group B) received 200 mg of mifepristone, followed after 48 hours by oral misoprostol. Successful treatment was an empty uterus on scan and no bleeding after 10 days. This was achieved in 70.5% of group A and 66.7% of group B. Also studied were amount and time to cessation of bleeding, pain scores, analgesic requirements, adverse effects and infections. Of group A, 54.5% had heavy bleeding and bleeding stopped on average by 8 days. Median pain scores were 5.5 on a linear scale and 18% of women received intramuscular opiate analgesia. Adverse effects were nausea in 25% of women and diarrhoea in 16%. Of group B, 38.3% had heavy bleeding and bleeding stopped on average by 7 days. Median pain scores were 4.5 with 25% of women receiving intramuscular opiates. Nausea occurred in 7% of women and diarrhoea in 7%. We concluded that 200 mg of mifepristone and oral misoprostol is as effective and better tolerated than 600 mg mifepristone with oral misoprostol. Medical management of miscarriage is a valid option for those women seeking an alternative to traditional surgical management.

Medical management of first trimester incomplete miscarriage using misoprostol

This prospective study looked at the effectiveness of 400 microg oral misoprostol in the management of women with a first trimester incomplete miscarriage with retained products of conception measuring between 15 mm and 50 mm on transvaginal ultrasound scan. Of 164 eligible women, 131 agreed to participate. Successful treatment, defined as an empty uterus on scan after 10 days with no bleeding, was achieved in 77.7% of women. Some women with retained products opted to have further misoprostol or conservative management instead of surgical evacuation and in total 92.4% of women completed their miscarriage without requiring surgery. Most bleeding was mild (31.3%) to moderate (38.9%), lasting on average 6.4 days. Forty-five per cent of women needed no pain relief, 51% received oral analgesia and 4% intramuscular opiates. Adverse effects included nausea (10.93%), diarrhoea (2.34%), vomiting (7.8%) and hypotension (4.68%). There were no infections. We concluded that a single dose of 400 microg of oral misoprostol was an effective treatment for women presenting with an incomplete miscarriage.

Women's preferences for attributes of first-trimester miscarriage management: a stated preference discrete-choice experiment

OBJECTIVE

To elicit women's preferences for attributes of alternative management options for first-trimester miscarriage.

METHODS

A stated preference discrete-choice experiment was conducted among 1198 women with a confirmed pregnancy of less than 13 weeks gestation, who had been diagnosed with either an incomplete miscarriage or missed miscarriage/early fetal demise and who had been recruited as part of a randomized controlled trial (miscarriage treatment [MIST] trial) comparing expectant, medical, and surgical miscarriage. Six attributes, each with three or four levels, were used in the statistical design. An orthogonal main effects design was generated (i.e., a design where the attributes are independent of each other) and the choice sets devised according to the principles of minimum overlap and level balance. A cost attribute was included to allow estimation of willingness to pay (WTP) values. Three different questionnaires were designed such that women were asked their preferences for attributes of the two management options they had not been allocated to in the trial.

RESULTS

A total of 630 women completed the stated preference discrete-choice survey questionnaires: 189 out of 398 women (47.5%) allocated to expectant management, 223 out of 398 women (56.0%) allocated to medical management, and 218 out of 402 women (54.2%) allocated to surgical management. For each of the three discrete-choice survey questionnaires, women expressed a clear preference for decreased levels of all six attributes (time spent at the hospital receiving treatment, level of pain experienced, number of days of bleeding after treatment, time taken to return to normal activities after treatment, cost of treatment to women, and chance of complications requiring more time or readmission to hospital). For each of the three discrete-choice survey questionnaires, the highest valued attribute in terms of WTP was for a reduction in pain levels followed by time taken to return to normal activities after treatment. On aggregate, surgical management was valued more highly than expectant and medical management by women allocated to medical and expectant management, respectively, and medical management was valued more highly than expectant management by women allocated to surgical management. This held true regardless of the application of either hypothetical data for each attribute generated by the pretrial-designed discrete-choice experiment questionnaires or actual data for each attribute observed in the MIST trial.

CONCLUSIONS

The preference results generated by this study suggest that many women undergoing management of first-trimester miscarriage would value being offered alternatives to expectant management. The data from this study should be considered by decision-makers in conjunction with the clinical and cost-effectiveness evidence base in this area as well as consideration of the budgets available to them for such services.

Vaginal Misoprostol in the Management of First Trimester Non-viable Pregnancy

To study the effectiveness of a regimen of repeated doses of vaginal misoprostol in the management of first trimester missed abortion, one hundred andfour pregnant women with first trimester non-viable pregnancies were treated with an initial dose of800 g of vaginal misoprostol followed after four hours by further doses of400 ! g fourhourly for a maximum of three doses. The complete expulsion rate was 85.6%. Fifty of the 104 (48.1%) women underwent surgical evacuation. In 14 (135%) women, gestational products were obtained and confirmed by histopathological examination. In 36 (34.6%) there were minimal or no products obtained and these were considered to be complete miscarriages. The cervical os was found open in all (135%) the incomplete miscarriages. Severe abdominal pain was experienced by 10.6% of the patients and excessive vaginal bleeding occurred in 135% of them. A fall in hemoglobin of more than one gramldl occurred in 5.8% of the women and another 5.8% of them had fever > 38°C. The stay in hospital was two days for 87 (83.7%) women and three days for 15 (14.4%) women. One (1%) woman stayed four days and another stayed less than one day. None of the women had any complications. This study demonstrated the efficacy and safety of vaginal misoprostol as a medical treatment for first trimester non-viable pregnancies using an initial dose of 800 g, followed after four hours by further doses of 400 ! g four-hourly for a maximum of three doses. This management also provided adequate cervical dilatation for surgical evacuation when complete expulsion did not occur.

Treatment of incomplete abortion and miscarriage with misoprostol

A literature review was conducted to determine whether misoprostol is an effective treatment for incomplete abortion and, if so, to recommend an appropriate regimen. All English language articles published before October 2007 using misoprostol in at least one of the study arms were reviewed to determine the efficacy of misoprostol when used to treat incomplete abortion in the first trimester. All available unpublished data previously presented at international scientific meetings were also reviewed. Sufficient evidence was found in support of misoprostol as a safe and effective means of non-surgical uterine evacuation. A single dose of misoprostol 600 microg oral is recommended for treatment of incomplete abortion in women presenting with a uterine size equivalent to 12 weeks gestation.

Is misoprostol a safe, effective and acceptable alternative to manual vacuum aspiration for postabortion care? Results from a randomised trial in Burkina Faso, West Africa

OBJECTIVES

Previous research has demonstrated the effectiveness of misoprostol for treatment of incomplete abortion; however, few studies have systematically compared misoprostol's effectiveness with that of standard surgical care. This study documents the effectiveness of a single 600 micrograms dose of oral misoprostol versus manual vacuum aspiration (MVA) for treatment of incomplete abortion in a developing country setting.

DESIGN

Open-label randomised controlled trial.

SETTING

Two university teaching hospitals in Burkina Faso, West Africa.

POPULATION

Women of reproductive age presenting with incomplete abortion.

METHODS

From April 2004 through October 2004, 447 consenting women with incomplete abortion were randomised to either a single dose of 600 micrograms oral misoprostol or MVA for treatment of their condition.

MAIN OUTCOME MEASURE

Completed abortion following initial treatment.

RESULTS

Regardless of treatment assigned, nearly all participants had a complete uterine evacuation (misoprostol = 94.5%, MVA = 99.1%; relative risk [RR] = 0.95 [95% CI 0.92-0.99]). Acceptability and satisfaction ratings were similar and high for both misoprostol and MVA, with three out of four women indicating that the treatment's adverse effects were tolerable (misoprostol = 72.9%, MVA = 75.8%; RR = 0.96 [95% CI 0.86-1.07]). The majority of women were 'satisfied' or 'very satisfied' with the method they received (misoprostol = 96.8%, MVA = 97.7%; RR = 0.99 [95% CI 0.96-1.02]), expressed a desire to choose that method again (misoprostol = 94.5%, MVA = 86.6%; RR = 1.09 [95% CI 1.03-1.16]) and to recommend it to a friend (misoprostol = 94.5%, MVA = 85.2%; RR = 1.11 [95% CI 1.04-1.18]).

CONCLUSION

Six hundred micrograms of oral misoprostol is as safe and acceptable as MVA for the treatment of incomplete abortion. Operations research is needed to ascertain the role of misoprostol within postabortion care programmes worldwide.

Medical management of early pregnancy failure in a patient with coronary artery disease

OBJECTIVE

To describe a case of early pregnancy failure in a patient who was not an optimal candidate for suction aspiration because of her body habitus and history of a myocardial infarction that was treated medically with misoprostol.

DESIGN

Case report.

SETTING

Academic tertiary-care hospital.

PATIENT

A 43-year-old woman with morbid obesity, coronary artery disease, previous myocardial infarction, obstructive sleep apnea, and other medical problems who presented with an early pregnancy failure.

INTERVENTION

Medical management with 800 microg of vaginal misoprostol in an inpatient setting with cardiac monitoring.

MAIN OUTCOME MEASURE(S)

Ultrasonographic resolution of intrauterine pregnancy, vaginal bleeding, and cardiac events.

RESULT(S)

No gestational sac was visualized by ultrasound on the second hospital day, the patient's hemoglobin value at discharge was 12.1 mg/dL, and no adverse cardiac events occurred.

CONCLUSION(S)

Medical management with misoprostol on an inpatient basis is a possible alternative to dilation and curettage in patients with complex medical problems and early pregnancy failure.

Contemporary management of early pregnancy failure

Early pregnancy failure is a common pregnancy complication. This paper reviews the terminology, diagnosis, and treatment of early pregnancy failure. Although surgical curettage has been the standard of care for more than 50 years, additional treatment options exist which appear to be satisfactory to patients. Manual vacuum curettage in the office is an effective alternative to electric vacuum curettage in an operating room. Nonsurgical treatments, including expectant and medical management, are reasonable alternatives depending on the clinical situation and the patient's desires. Clinicians need to understand how these options compare to provide appropriate counseling to patients.

Psychological morbidity following miscarriage

Emerging evidence has suggested that miscarriage could be associated with significant and possibly enduring psychological consequences. As many as 50% of miscarrying women suffer some form of psychological morbidity in the weeks and months after loss. About 40% of miscarrying women were found to be suffering from symptoms of grief shortly after miscarriage, and pathological grief can follow. Elevated anxiety and depressive symptoms are common, and major depressive disorder has been reported in 10-50% after miscarriage. Psychological symptoms could persist for 6 months to 1 year after miscarriage. The underlying risk factors predisposing a miscarrying woman to psychological morbidity include a history of psychiatric illness, childlessness, lack of social support or poor marital adjustment, prior pregnancy loss, and ambivalence toward the fetus. In addition, care-givers should be aware of the possible moderating effect of clinical practices such as surgical treatment and ultrasound findings on the psychological impact on a miscarrying woman. Unlike in postpartum depression, simple and effective screening measures of psychological morbidity in the context of miscarriage have not been well established. While studies have highlighted that psychological follow-up was highly desired by miscarrying women, and that psychological intervention was potentially beneficial, there is a substantial lack of randomized controlled intervention studies in this area.

Bleeding patterns after misoprostol vs surgical treatment of early pregnancy failure: results from a randomized trial

OBJECTIVE

The purpose of this study was to describe bleeding patterns after misoprostol or curettage for early pregnancy failure (EPF).

STUDY DESIGN

This was a randomized trial that included women (n = 652) with EPF. Participants were assigned to vaginal misoprostol (800 microg) or curettage in a 3:1 ratio. Participants completed a bleeding diary. We measured hemoglobin levels at baseline and 2 weeks after the treatment.

RESULTS

Decreases in hemoglobin levels were greater after misoprostol (-0.7 g/dL; SD, 1.2) than curettage (-0.2 g/dL; SD, 0.9; P < .001). Large changes in hemoglobin levels (at least 2 g/dL) or low nadir hemoglobin levels (< 10 g/dL) were more frequent after misoprostol (55/428 women; 12.8%) than after curettage (6/135 women; 4.4%; P = .02). More participants in the misoprostol group reported "any bleeding" or "heavy bleeding" every study day. Four women who were treated with misoprostol required blood transfusion.

CONCLUSION

Bleeding is heavier and more prolonged after medical treatment with misoprostol than with curettage for EPF; however, bleeding rarely requires intervention.

A randomized prospective study of misoprostol or mifepristone followed by misoprostol when needed for the treatment of women with early pregnancy failure

OBJECTIVE

To compare the effectiveness and safety of misoprostol and mifepristone, followed when needed by misoprostol, for the treatment of women with early pregnancy failure.

DESIGN

Prospective randomized nonblinded controlled trial.

SETTING

University-affiliated tertiary medical center.

PATIENT(S)

One hundred fifteen consecutive women diagnosed as having a blighted ovum or missed abortion of <9 weeks of gestation enrolled.

INTERVENTION(S)

The patients received orally 600 mg mifepristone (group I) or orally 800 microg misoprostol (group II). Most patients in both groups subsequently received 48 hours later orally 800 microg misoprostol.

MAIN OUTCOME MEASURE(S)

Failure was defined as surgical intervention due to retained gestational sac 48 hours after completion of the drug protocol, severe symptoms, or suspected retained products of conception after the menstrual period.

RESULT(S)

The success rate was similar in groups I and II: 38 of 58 patients (65.5%) versus 42 of 57 patients (73.6%), respectively. No cases of severe infection or bleeding necessitating blood transfusion occurred.

CONCLUSION(S)

Misoprostol is an effective and safe treatment for early pregnancy failure and could replace surgical curettage in over two-thirds of the patients. Mifepristone offers no advantage compared with misoprostol as initial treatment.

Common problems and emergencies in the obstetric patient

Physicians not used to caring for pregnant patients may feel uncomfortable dealing with the many routine problems that can occur during a pregnancy. Other than true obstetric emergencies, which are usually cared for by obstetricians and family physicians, and the common problems of pregnancy can often be cared for by any primary care physician. Given the litigious nature of our society, especially in the realm of obstetrics, it does behoove the physician caring for pregnant women to be aware of the standards of care. When in doubt, it would be prudent to consult with a physician that routinely provides care to pregnant women.

Economic evaluation of alternative management methods of first-trimester miscarriage based on results from the MIST trial

OBJECTIVES

To compare the cost-effectiveness of alternative management methods of first-trimester miscarriage.

DESIGN

Economic evaluation conducted alongside a large randomised controlled trial (the MIST trial).

SETTING

Early pregnancy assessment units of seven participating hospitals in southern England.

SAMPLE

A total of 1200 women with a confirmed pregnancy of less than 13 weeks of gestation with a diagnosis of incomplete miscarriage or missed miscarriage.

METHODS

Random allocation to expectant management, medical management or surgical management. Collection of health service and broader resource use data, unit costs for each resource item and clinical outcomes.

MAIN OUTCOME MEASURES

Costs (pounds, 2001-02 prices) to the health service, social services, women, carers and wider society during the first 8 weeks postrandomisation. Cost-effectiveness estimates, expressed in terms of incremental cost per gynaecological infection prevented; cost-effectiveness acceptability curves presented at alternative willingness-to-pay thresholds for preventing gynaecological infection.

RESULTS

There was no significant difference in the incidence of gynaecological infection between groups. The net societal cost per woman was estimated at 1086.20 pounds in the expectant group, 1410.40 pounds in the medical group and 1585.30 pounds in the surgical group. Expectant management had a 97.8% probability of being the most cost-effective management method at a willingness-to-pay threshold of 10,000 pounds for preventing one gynaecological infection, while medical management had a 2.2% probability of being the most cost-effective management method. Expectant management retained the highest probability of being the most cost-effective management method at all willingness-to-pay thresholds of less than 70,000 pounds for preventing one gynaecological infection.

CONCLUSIONS

Expectant and medical management of first-trimester miscarriage possess significant economic advantages over traditional surgical management.

Management of miscarriage: expectant, medical, or surgical? Results of randomised controlled trial (miscarriage treatment (MIST) trial)

OBJECTIVE

To ascertain whether a clinically important difference exists in the incidence of gynaecological infection between surgical management and expectant or medical management of miscarriage.

DESIGN

Randomised controlled trial comparing medical and expectant management with surgical management of first trimester miscarriage.

SETTING

Early pregnancy assessment units of seven hospitals in the United Kingdom.

PARTICIPANTS

Women of less than 13 weeks' gestation, with a diagnosis of early fetal demise or incomplete miscarriage.

INTERVENTIONS

Expectant management (no specific intervention); medical management (vaginal dose of misoprostol preceded, for women with early fetal demise, by oral mifepristone 24-48 hours earlier); surgical management (surgical evacuation).

MAIN OUTCOME MEASURES

Confirmed gynaecological infection at 14 days and eight weeks; need for unplanned admission or surgical intervention.

RESULTS

1200 women were recruited: 399 to expectant management, 398 to medical management, and 403 to surgical management. No differences were found in the incidence of confirmed infection within 14 days between the expectant group (3%) and the surgical group (3%) (risk difference 0.2%, 95% confidence interval - 2.2% to 2.7%) or between the medical group (2%) and the surgical group (0.7%, - 1.6% to 3.1%). Compared with the surgical group, the number of unplanned hospital admissions was significantly higher in both the expectant group (risk difference - 41%, - 47% to - 36%) and the medical group (- 10%, - 15% to - 6%). Similarly, when compared with the surgical group, the number of women who had an unplanned surgical curettage was significantly higher in the expectant group (risk difference - 39%, - 44% to - 34%) and the medical group (- 30%, - 35% to - 25%).

CONCLUSIONS

The incidence of gynaecological infection after surgical, expectant, and medical management of first trimester miscarriage is low (2-3%), and no evidence exists of a difference by the method of management. However, significantly more unplanned admissions and unplanned surgical curettage occurred after expectant management and medical management than after surgical management. TRIAL REGISTRATION NATIONAL RESEARCH REGISTER: N0467011677/N0467073587.

Factors related to successful misoprostol treatment for early pregnancy failure

OBJECTIVE

To identify potential predictors for treatment success in medical management with misoprostol for early pregnancy failure.

METHODS

We conducted a planned secondary analysis of data from a multicenter trial that compared medical and surgical management of early pregnancy failure. Medical management consisted of misoprostol 800 mug vaginally on study day 1, with a repeat dose if indicated on day 3. Women returned on days 3 and 15, and a telephone interview was conducted on day 30. Failure was defined as suction aspiration for any reason within 30 days. Demographic, historical, and outcome variables were included in univariable analyses of success. Multivariable analyses were conducted using clinical site, gestational age, and variables for which the univariable analysis resulted in a P < .1 to determine predictors of overall treatment success and first-dose success.

RESULTS

Of the 491 women who received misoprostol, 485 met the criteria for this secondary analysis. Lower abdominal pain or vaginal bleeding within the last 24 hours, Rh-negative blood type, and nulliparity were predictive of overall success. However, only vaginal bleeding within the last 24 hours and parity of 0 or 1 were predictive of first-dose success. Overall success exceeds 92% in women who have localized abdominal pain within the last 24 hours, Rh-negative blood type, or the combination of vaginal bleeding in the past 24 hours and nulliparity.

CONCLUSION

Misoprostol treatment for early pregnancy failure is highly successful in select women, primarily those with active bleeding and nulliparity. Clinicians and patients should be aware of these differences when considering misoprostol treatment.

LEVEL OF EVIDENCE

II-2.

Expectant care versus surgical treatment for miscarriage

BACKGROUND

Miscarriage is a common complication of early pregnancy that can have both medical and psychological consequences like depression and anxiety. The need for routine surgical evacuation with miscarriage has been questioned because of potential complications such as cervical trauma, uterine perforation, hemorrhage, or infection.

OBJECTIVES

To compare the safety and effectiveness of expectant management versus surgical treatment for early pregnancy loss.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2004, Issue 3), PubMed (1966 to March 2005), POPLINE (inception to March 2005), and LILACS (1982 to March 2005) and reference lists of reviews.

SELECTION CRITERIA

Randomized trials comparing expectant care and surgical treatment (vacuum aspiration or dilation and curettage (D & C)) for miscarriage were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information.

MAIN RESULTS

Five trials were included in this review with 689 total participants. The expectant-care group was more likely to have an incomplete miscarriage (RR 5.37; 95% CI 2.57 to 11.22). However, the time frames for declaring the process incomplete varied across the studies. The need for unplanned surgical treatment (such as vacuum aspiration or D&C) was greater for the expectant-care group (RR 4.78; 95% CI 1.99 to 11.48). The expectant-care group had more days of bleeding (WMD 1.59; 95% CI 0.74 to 2.45) and a greater amount of bleeding (WMD 1.00; 95% CI 0.60 to 1.40). Post-procedure diagnosis of infection was lower in the expectant-care group (RR 0.29; 95% CI 0.09 to 0.87). Information on psychological outcomes and pregnancy was too limited to draw conclusions.

AUTHORS' CONCLUSIONS

Expectant management led to a higher risk of incomplete miscarriage, need for surgical emptying of the uterus, and bleeding. None of these were serious. In contrast, surgical evacuation was associated with a significantly higher risk of infection. Given the lack of clear superiority of either approach, the woman's preference should play a dominant role in decision making. Medical management has added choices for women and their clinicians, but these were not reviewed here.

A randomised trial of surgical, medical and expectant management of first trimester spontaneous miscarriage

BACKGROUND

Medical management and expectant care have been considered possible alternatives to surgical evacuation of the uterus for first trimester spontaneous miscarriage in recent years.

AIM

To compare the effectiveness and safety of medical and expectant management with surgical management for first trimester incomplete or inevitable miscarriage.

METHODS

Forty women were recruited following diagnosis of incomplete or inevitable miscarriage, and randomised to surgical, medical or expectant care via an off-site, computerised enrollment system. The primary outcome was the effectiveness of medical (vaginal misoprostol) and expectant management relative to surgical evacuation, assessed at 10-14 days and 8 weeks post-recruitment. Infection, pain, bleeding, anxiety, depression, physical and emotional recovery were assessed also. Analysis was by intention-to-treat.

RESULTS

Effectiveness at 8 weeks was lower for medical (80.0%) and expectant (78.6%) than for surgical management (100.0%). Two women in the medical group had confirmed infections. Bleeding lasted longer in the expectant group than in the surgical group. There were no significant differences in pain, physical recovery, anxiety or depression between the groups. 54.6%, 42.9% and 57.1% of the surgical, medical and expectant groups respectively would opt for the same treatment again.

CONCLUSION

Expectant care appears to be sufficiently safe and effective to be offered as an option for women. Medical management might carry a higher risk of infection than surgical or expectant care.